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Publishedby:
MinistryofHealth,WelfareandSport
Addressforvisitors:
Parnassusplein5
2511VXTheHague
TheNetherlands
Correspondenceaddress:
PObox20350
2500EJTheHague
TheNetherlands
Telephone+31(0)703407911
Telefax+31(0)703407834
Internet:
www.minvws.nl
May2006
ICT in Dutch Healthcare:An International Perspective
� ICTinDutchHealthcare:AnInternationalPerspective � ICTinDutchHealthcare:AnInternationalPerspective
Contents
1 Summary 5
2 Introduction 7
2.1 ThehealthcaresystemintheNetherlands 7
2.2 Aimoftheroadmap 8
3 Healthcare and ICT in the Netherlands 9
3.1 ElectronicHealthRecord 9
3.2 AORTAbasicinfrastructure 11
3.3 EMD/WDHimplementationprogramme 14
3.4 Otheraspects 15
3.5 Conditions 16
3.5.1 Legislativeframework 16
3.5.2 Funding 17
3.5.3 Coordination 17
4 EU eHealth Action Plan 19
4.1 Introduction 19
4.2 Astrategyforcommonchallenges 19
4.3 Pilotprojects 22
4.4 Monitoring 23
Appendix1:HealthIndicators-TheNetherlands 25
Appendix2:Nationalexpenditureonhealth-TheNetherlands 26
Appendix3:HealthcareProfessionals2003-TheNetherlands 28
� ICTinDutchHealthcare:AnInternationalPerspective � ICTinDutchHealthcare:AnInternationalPerspective
1 Summary
TheDutchgovernmentisworkingwithplayersinthehealthcaresectortodevelop
anationwidesystemforsecureandreliableelectronicexchangeofmedicaldata.
Manyinitiativeshavealsobeenlaunchedintheinternationaldomaintoimprovethe
deploymentofICTinhealthcare.Thisroadmapisaworkingdocumentwhichpresents
theDutchpositiononICTinhealthcareinaninternationalperspective.
ICTsupplierscanuseDutchdesignsforICTarchitectureinthehealthcaresectorand
theaccompanyingspecificationsasabasisforintegratingtherequiredfunctionsin
thesystemsofhealthcareprovidersandhealthinsurers,thusenablinghealthcare
professionalstoexchangedigitalinformationonanationalscale.Theroadmapdiscusses
theconstituentsofthebasicinfrastructureandtheapplications.
ForidentificationandauthenticationwedistinguishbetweentheCitizenServiceNumber
(BSN)foridentifyingpatients,theUniqueHealthcareProfessionalIdentification(UZI)for
identifyinghealthcareproviders,andtheUniqueHealthInsurerIdentification(UZOVI)for
identifyinghealthinsurers.
InJanuary2006aNationalSwitchPoint(LSP)wasbuiltwithareferenceindexfor
routing,identification,authentication,authorizationandlogging.TheNationalSwitch
Pointactsasasortof‘trafficcontroltower’throughwhichhealthcareproviderscan
requestrecentpatientdatafromthesystemsofhospitals,pharmaciesandGPs.
HealthcareinstitutionscanlogontotheNationalSwitchPointviathenetworksof
commercialproviders–CareServiceProviders–ofcommunication,applicationand
contentservices.Thedatainlocalsystemsneedtobesystematicallystoredandsecured
andmeetthecriteriaforaWell-ManagedHealthcareSystem(GBZ)
TheDutchgovernmenthasoptedfortheincrementaldevelopmentofanElectronic
HealthRecord(EPD).Thisconsistsofacollectionofapplicationswhichareconnected
tothenationalinfrastructure.ThespearheadsaretheintroductionofanElectronic
MedicationRecord(EMD)andanElectronicGeneralPractitioner’sRecord(WDH),but
manyotherhealthcareapplicationsarealsobeingdeveloped.
Thecomponentsofthebasicinfrastructureandthefirsttwoapplicationscometogether
intheEMD/WDHimplementationprogramme.Toensureasmoothtransitionseveral
regionshavebeenselectedas‘pilots’andtheimplementationprocesshasbeensplit
intothreephases,startingwithaProofofConceptinwhichalltheconstituentsofthe
chainaretestedincombinationunderlaboratoryconditions.Thiswillbefollowedby
implementationinthereferenceenvironmentsandthenintheotherpilotregions.
� ICTinDutchHealthcare:AnInternationalPerspective � ICTinDutchHealthcare:AnInternationalPerspective
TheimplementationofanationwideElectronicHealthRecordintheNetherlandsis
basedontheassumptionthatprimaryresponsibilityforthequalityofthecareandthe
useoftheICTsystemsrestswiththeproviders.Thegovernment’sroleistopavetheway
bypassinglegislation,creatingtherightinvestmentclimate,andcoordinatingtheoverall
process.
Section3addressestheactivitiesbeingcarriedoutintheNetherlandsinrelationtothe
EUeHealthActionPlanof2004.
2 Introduction
Healthcareisprovidedbyhumans–and,aseverybodyknows,humansarenotinfallible
andsometimesmakemistakes.Technologyhasalottoofferinsupportofhumaneffort.
OneareawhereICTcanplayacrucialroleistheexchangeofmedicaldata.Ifhealthcare
providersweretohaveaccesstoaccurateandrecentdata,theywouldbeinafarbetter
positiontoprovidetherequisitecare.
TheMinistryofHealth,WelfareandSportisworkingwiththeNationalITInstitutefor
Healthcare(NICTIZ)1andtheCentralInformationPointforHealthcareProfessions(CIBG)2
onthedevelopmentofanationwidesystemfortheelectronicexchangeofmedicaldata.
ThissystemisknownastheElectronicHealthRecord(EPD).
However,thepromotionofICTinhealthcare(eHealthcare)doesnotstopatthe
geographicalbordersoftheNetherlands.Manyinitiativeshavealsobeenlaunchedinthe
internationaldomain,aimedatimprovingtheaffordability,accessibilityandqualityof
healthcarethroughthedeploymentofICT.Another–related–trendisincreasingmobility
amongpatientsandprofessionals.Furtherobjectivesarebeingpursuedatpoliticallevel
togiveshapeandformtotrans-bordermobilityand(preventive)medicine.
2.1 The healthcare system in the Netherlands
ThehealthcaresystemintheNetherlandsconsistsofthreecompartments.Thefirstcovers
long-termcareandtheso-called‘uninsurable’medicalrisks.Thecareinthiscompartment
islargelyprovidedandfundedbythestateviatheExceptionalMedicalExpensesAct
(AWBZ).
Thesecondcoversshort-termmedicalcare(cure)whichshouldbeuniversallyaccessible.
Thecareinthiscompartmentisprovidedandfundedbythestateandtheinsurers.
Thethirdcoversthecarethatisnotincludedinthefirstorsecondcompartmentandfor
whicheveryonecanvoluntarilyinsurethemselves;typicalexamplesaredentaltreatment
andalternativemedicine.
TheageingpopulationwillintensifythepressureontheDutchhealthcaresystem.More
andmorepeoplewilldevelopchronicconditionssuchasdiabetes,cardio-vascular
diseaseandbronchialcomplaints.Theaccessibility,affordabilityandqualityofthecare
mustcontinuetobeguaranteed.Itisforthisreasonthatanumberofchangeswere
introducedin2006.
1 TheNICTIZisaneutralandindependentorganizationwhichwasfoundedin2002byvariousplayersinthe
healthcaresector.Itisresponsibleforthedesignandconstructionofthenationwidebasicinfrastructureandforthe
developmentofstandardsforanElectronicHealthRecord.Formoreinformationseewww.nictiz.nl
2 TheCIBG(www.cibg.nl)consistsofninedifferentunitsandisanexecutivearmoftheMinistryofHealth,Welfare
&Sport.Theregistrationofdataandtheprovisionofinformationareamongitsmostimportanttasks.Eachunit
specializesinaspecificsegmentofthecaremarket.
� ICTinDutchHealthcare:AnInternationalPerspective � ICTinDutchHealthcare:AnInternationalPerspective
Thesechanges,whicharedesignedtopreparethesystemforthefutureandtomake
thehealthcaremoreeffective,efficientandcustomer-focused,necessitateabetter
distributionofresponsibilityamongthekeyplayers.Thepatient/clientoccupiesacentral
roleinthecurrenthealthcaresystemintheNetherlands,withmoreopportunitiesbut
alsomoreresponsibility.Itisuptothepatient/clienttobringaboutimprovementsto
thequality.Awell-informedpatientcansingleouttheproviderthatoffersthebestcare
forhiscondition.Thiswillspurhealthcareproviders(doctors,hospitalboards,etc.)to
raisetheirperformance.Medicalinsurerswillbearmoreresponsibilityformatchingthe
demandsoftheconsumerwiththeofferingsoftheproviders.Itisthegovernment’sjob
tooverseequality,accessibilityandaffordability.
TheDutchhealthcaresystemtakestheformofaninsurancesystemwhichisrunby
privateproviderswithapublicremit.Thisset-upalsoappliestotheICTpolicyandrole
allocationinthehealthcaresector.Thegovernment,inthiscasetheMinistryofHealth,
Welfare&Sport,wantstopromotetheuseofICTinhealthcarewiththeultimateaimof
improvingaffordability,accessibilityandquality.Itwilldosobycreatingaclimatewhich
isconducivetooptimalandsecureuseofICT.Thehealthcareprovidersbearprimary
responsibilityforthequalityofthecareandtheuseofICTsystems.
2.2 Aim of the roadmap
Internationalcooperationmeansthat,ifwecanshareourdatahereintheNetherlands,
thenEuropeaninteroperabilitymustalsobeachievable.TheNetherlandsfavoursa
pragmaticapproach:memberstatesshouldpreparethemselvesfortrans-Europe
exchangeofmedicaldatainthefutureandreachsomeformofagreement.
TheaimofthisroadmapistopresenttheDutchstandpointonICTinhealthcareinan
internationalperspective.ItbeginsbydescribingthecurrentsituationintheNetherlands
andthenoutlinestheexpectedsituationafter2006.Itexplainsthedecisionstodeploy
ICTintheDutchhealthcaresystemandpositionstheminrelationtopolicyanddecisions
inEurope.Finally,itsetstheDutchgovernment’stimetableforICTinhealthcareinan
internationalperspective.
Thisroadmapisintendedprimarilyforpolicymakersandpolicyexecutivesinthe
Netherlandsandabroad.Itprovidesasnapshotimageofnationaldevelopmentsin
relationtotheeHealthprogrammeoftheEUandwillbepresentedattheHighLevel
eHealthconferenceinMalaga(10-12May2006).Thetimetableisbasedonthenational
focusanddevelopments.Partsoftheroadmap,however,needtobefurtherfleshedout
nationallyandinternationally.Discussionsareneededatvariouslevelsforthispurpose.
3 Healthcare and ICT in the Netherlands
ThissectionexplainsthehealthcareandICTsituationintheNetherlands.Thefirstpart
willaddresstheapplicationsoftheElectronicHealthRecord(EPD).Thesecondwill
discussthevariouscomponentsofthenationalbasicinfrastructure.Thethirddeals
withtheimplementationprogrammefortheElectronicMedicationRecord(EMD)and
theElectronicGeneralPractitioner’sRecord(WDH,paragraph3.3)inwhichthesetwo
functionswillbetestedtogetherforthefirsttime.Attentionwillalsobepaidtoother
ICTdevelopmentsinthehealthcaresector,suchasconsultationsbye-mail.Thefinal
paragraphwilldiscusstheinstrumentswhichtheDutchgovernmentcanemployto
realizeallofthis.
3.1 Electronic Health Record
TheNetherlandshasitssightssetonanationaltransmuralElectronicHealthRecord
(EPD):asecureenvironmentinwhichclient/patientdatawhicharestoredindifferent
systemscanberetrieved,exchangedandcogentlyshowntoauthorizedhealthcare
providerstosupportthehealthcareprocesses.
This‘virtual’EPDconsistsofacollectionofapplicationswhichareconnectedtothe
nationalAORTAinfrastructure.ThespearheadsaretheintroductionofanElectronic
MedicationRecord(EMD)andanElectronicGeneralPractitioner’sRecord(WDH),but
manymorecareapplicationsarebeingdeveloped.TheNetherlandsismovingtowards
afully-fledgedEPD.
A Electronic Medication Record (EMD)
TheElectronicMedicationRecordgiveshealthcareprovidersinsightintothemedication
historyofspecificpatientsviatheirowninformationsystem.Thisinformationstaysat
thesource(informationsystemofahospital,pharmacy,GPpracticeetc.)butisavailable
toprovidersandprescribersofmedication:publicpharmacies,hospitalpharmacies,
GPpractices,locumposts,hospitals,mentalhealthinstitutionsandresidentialcareand
nursinghomes.
ResearchbytheDutchpharmaceuticalassociation,theWetenschappelijkInstituut
NederlandseApothekers,hasrevealedthatanestimated90,000patientsareadmitted
tohospitaleveryyearasaresultofmedicationerrorsthatcouldhavebeenavoided.
Thiscostsaround300millioneurosayearandaccountsforapproximately2.5%of
hospitalizationnationwide.Ifhealthcareprovidershaveelectronicaccesstoallthe
medicationdataoftheirpatient,alotofsufferingandinconveniencecanbeavoidedand
alargepartofthissumcanbesaved.
B Electronic General Practitioner’s Record (WDH)
TheGPshortage,anageingpopulation,anageingprofessionalgroup,plusthefactthat
mostnewlyqualifiedGPsprefertoworkpart-timehaveprecipitatedtheemergenceof
10 ICTinDutchHealthcare:AnInternationalPerspective 11 ICTinDutchHealthcare:AnInternationalPerspective
LocumPostsinrecentyears.AtthemomenttheGPswhostandinfortheircolleagues
atLocumPostsintheeveningsandweekendshavehardlyanyaccesstothemedical
historyofthepatients.Insomecasesthispreventsthelocumfrommakinganadequate
diagnosis.ItisnotalwayspossibletogettherequiredinformationfromtheregularGP.
Whatismore,manypatientsareunabletoprovidecrucialinformationandsometimes
cannotevenrecallthenameofthemedicationtheyaretaking.
AnElectronicGeneralPractitioner’sRecordwillprovidethelocumwithasummaryofthe
patient’shistory.TherecordswillremainwiththeregularGPandwillonlybeaccessible
toalocum.Informationgainedduringtheconsultationisautomaticallyrelayedtothe
regularGPintheformofalocumreport.Theinformationappearsonthescreenofthe
GP,whochecksitandaddsittotherecordswithaclickonthebutton.
C Extension of applications
Thefirststepshavealreadybeentaken.MostoftheICTagendaforthecomingperiod
isstilltobedetermined.Theintroductionofnewapplicationswillbeprioritizedonthe
basisofthetechnologicalpossibilitiesandthewishesofthepatients,thehealthcare
providersandtheinsurers.Inthenextfewyears,various‘chapters’willbeaddedtothe
EPD,whichwillbeextendedtootherprofessionalgroupsanddomains(welfare,juvenile
careetc.).Thisstep-by-stepapproachshouldeventuallyleadtoanumbrellacollection
ofexchangeabledataforalltheplayers.Atalleventsthefollowinginitiativeswillbe
launchedinthenearfuture:
• FurtherdevelopmentoftheEPDcomponents:
• ExtendtheEMDbyaddingelectronicprescriptionfunctionsforhealthcare
providers;
• ExtendtheEMDtootherprofessionalgroups;
• ExtendtheWDHtoAccident&Emergency;
• Developthecomponentsforanelectronicdiabetesfile(aroundthecomplex
chainofhealthcareproviders),startingwithaself-managementtoolwhichgives
patientsaccesstotheirowndiabetesdata;
• DevelopanElectronicChild’sRecord(EKD).From1January2007everychildbornin
theNetherlandswillhavehis/herownEKD,containinginformationonthechild,the
familysituationandtheenvironment.Therecordswillbeadministeredbydoctors
andnursesinthejuvenilecaresector.Variousorganizationswillbeabletoadd
observationstotherecordwithoutconsultingit.Thisway,theprivacyofthechildis
protectedwhilejuvenilecareworkerscanidentifyproblemssoonerandtakequicker
action.
• UpsizeproveneHealthapplicationsbymeansofvariousprogrammes(e.g.the
NationwideProgrammeforSocialSectorsandICT).3
3 TorealizebreakthroughsinupsizingtheICTapplicationsandservicestheDutchgovernmentwillhavetotake
theleadinresolvingstickingpoints.ResponsibilityhasbeendelegatedtotheNationwideProgrammeforSocial
SectorsandICT(2005-2009)whichcoversfourdomains(mobility,education,safetyandhealthcare).
• Createconditionswherebypatientsgetelectronicaccesstotheirownrecord.Atthe
momentpolicymakersarethinkingintermsofanelectronicNationalIdentityCardas
ameansofpatientaccess.
The choices in the Netherlands:
• IncrementaldevelopmentofanElectronicHealthRecord.Newapplicationswill
beregularlyaddedtotheEPDintheyearsahead.
• GeneralPractitioner’sRecordasaninitialapplicationofanEPD.
• ElectronicMedicationRecordasaninitialapplicationofanEPD.
3.2 AORTA basic infrastructureInrecentyearstheDutchgovernment,theNationalICTInstituteforCare(NICTIZ)and
healthcareprofessionalshavetogetherlaidthefoundationfornationwideelectronic
communicationinthehealthcaresector.ICTsupplierscanuseDutchdesignsforICT
architectureinthehealthcaresectorandtheaccompanyingspecificationsasabasisfor
integratingtherequiredfunctionsinthesystemsofhealthcareprovidersandinsurers,
therebyenablingelectronicexchangeofinformationonanationalscale.Thesystems
ofthehealthcareprovidersandinsurersneedtobemodifiedsothattheycanbelinked
tothebasicinfrastructureandinordertorealizethedesiredlevelofsecurityand
accessibility.Thenationalbasicinfrastructureforhealthcareconsistsofanumberof
componentsandisdueforrealizationin2006.
A National registration systems for identification and authentication of patients,
healthcare providers, insurers and other care agencies
Nationalelectronicinformation-exchangeinvolvesthelinkingofdata.Toensurethat
dataisregisteredconsistentlyandthatpatients,healthcareprovidersandinsurers
communicatingatadistanceareproperlyidentified,uniquenationalidentification
numberswillbeapplied,namely:
1 TheCitizenServiceNumber(BSN)forpatientidentification.
Theintroductionofthisnumberatallgovernmentorganizationswillberegulated
bylaw.Separatelegislationwillbedrawnupfortheuseofthisnumberinthecare
sector.
2 UniqueHealthcareProfessionalIdentification(UZI)fortheidentificationofcare
providers.
Aregisterofcareprovidershasbeensetup,whichalsoseestotheissuingofUZI
passesandUZIcertificatesforidentifyingandauthenticatingcareproviders.Thefirst
passeswereissuedatthestartof2006.
3 UniqueHealthInsurerIdentification(UZOVI)fortheidentificationofhealthinsurers.
Aregisterofhealthinsurerswillalsobesetupandcertificateswillbeissuedto
confirmidentitieswhendataiselectronicallyexchanged.Thecertificateswillbe
issuedfromJanuary2007.
1� ICTinDutchHealthcare:AnInternationalPerspective 1� ICTinDutchHealthcare:AnInternationalPerspective
B A National Switch Point (LSP) with a reference index for routing, identification,
authentication, authorization and logging
On31January2006theNationalSwitchPoint(LSP)forthehealthcaresectorwas
established.Thisisanimportantstep,astheNationalSwitchPointisthe‘trafficcontrol
tower’behindthesecureelectronicexchangeofup-to-datepatientdatathroughoutthe
Netherlands.Inthesummerof2006theNationalSwitchPointwillbetestedwithICT
suppliersinthehealthcaresector.Afterwardsthehealthcareproviderscanbeconnected
toit.Thisisexplainedfurtherinsection3.3.
TheconstructionoftheNationalSwitchPointwascommissionedbyNICTIZ.Aftera
Europeantenderingprocedurethecontractwasawardedon8November2005.Actual
realizationtooklessthanthreemonths.
WiththeNationalSwitchPointasthetrafficcontroltower,healthcareprofessionalsall
overthecountrycanretrieveup-to-datepatientinformationfromthesystemsofhospitals,
pharmaciesandGPs.TheprimaryadvantageoftheNationalSwitchPointisthatcare
institutionsandsuppliersofICTapplicationsforthehealthcaresectorhaveonepointof
contactforspecificservices:
• TheNationalSwitchPointmanagesa‘nationalreferenceindex’whichcanswiftlytrack
patientdatawhenahealthcareproviderrequestsspecificinformation.Thepatientdata
arenotstoredatacentralpoint.Thereferenceindexkeepstrackofwhichpatientdata
arestoredinwhichinformationsysteminthecountry.
AtthesametimetheNationalSwitchPointconfirmsthatinformationissuppliedonly
tohealthcareproviderswiththerequisiteauthorization.Theswitchpointchecksthe
provideragainstthenationalUZIregister.Theprovidermustprovehisidentitywitha
UZIpass.
• TheNationalSwitchPointalsoconfirmswiththeaidoftheCitizenServiceNumberthat
thecorrectpatientdataarebeingsupplied.Thegovernmentisresponsibleforissuing
andcontrollingthisnationalpatientidentificationnumber.
• Finally,theNationalSwitchPointascertainswhichinformationthehealthcareprovider
mayaccess(authorization)andkeepsarecordoftheproviderandtheconsulteddata
(logging),sothattheauthorizationregulationscanbemonitored.
C Care Service Providers for communication and services between local environments
and the central LSP environment.
So,topromotesafeandfastcommunicationbetweencareorganizationsacrossthecountry
aNationalSwitchPoint(LSP)hasbeenestablished.Careorganizationscanconnectwiththe
LSPviathenetworkconnectionsofcommercialprovidersofcommunication,application
andcontentservices.Inthelongrunthese‘CareServiceProviders’willrequirecertification.
Intheinterim,asystemhasbeendevisedwherebymarketplayerscanbeauditedon
thebasisofaqualificationscheme.AsuccessfulauditcombinedwithasuccessfulLSP
acceptancetestleadstorecognitionasaCareServiceProvider.
D Information systems of care organizations
Careorganizationsneedtoasktheirsuppliertomodifytheirinformationsystemssothat
thedataisavailable24/7andcanbeaccessedbyauthorizedusers.Thismeansthatthe
datamustbestoredandsecuredinastructuredsystemandthatthelocalsystemscan
connectwiththeNationalSwitchPoint.Healthcareinformationsystemsneedtosatisfy
theGBZstandardsforwell-managedhealthcaresystems,wherebytheyalsomeetthe
internationalsecurityguidelines.Inaddition,careorganizations,healthcareproviders,
andlocalhealthcareinformationsystemsmustbeidentifiablewithauniquenationally
applicablenumber.
E Security and Authorization
Playersinthehealthcaresectorandpatientsmustbeconfidentthatthedatatransport
andstorageandaccesstopatientinformationisadequatelysecured.Awholearrayof
instrumentshasbeendevelopedforthispurpose.Accesscanbesecuredasfollows:
beforeaccesstocertaininformationisgranted,theidentityoftheapplicantisascertained
(identification)andconfirmed(authentication).Therightsoftheapplicanttoconsultthe
informationarethencheckedout(authorization).Messagesareencryptedtoensurethat
theinformationcannotbeinterceptedduringtransport.
Tooptimizesecurityallorganizationalandtechnicalaspectsneedtobeproperly
regulated.TheinfrastructureisPublicKeyInfrastructure(PKI),asystemoforganizational
andtechnicalrules,includingauthentication(Istheapplicantreallywhoheclaimstobe?),
dataencryptionandanelectronicsignature.PKIisthemostcommonlyusedsecurity
standard.Onesingleagencyconfirmstheaccessentitlementofthehealthcareprovider,
institutionorcomputersystemandissuesanelectroniccertificate.Thiscertificateisthen
usedtodeterminetheaccessrightsandregistertheidentityofthesender.
F Message standards
Informationexchangebetweenhealthcareprofessionalsrequiresmessagestandardsat
variouslevels.Messagesatapplicationlevelaredefinedfromoneinformationmodel
basedontheinternationalHL7version3standard.TheDutchhavedecidedtostandardize
on‘HL7version3’messagesbecausethisisaninternationalstandardwiththepotential
todevelopwithonestandardfromanationale-medicationrecordtoanationalElectronic
HealthRecord.ThespecificationshavebeenworkedoutindialoguewithHL7Nederland
andarebeingincorporatedintheinternationalHL7standard.
Ashealthcareinformationservicescoverabroadspectrumithasbeendecidedtogear
furtherdevelopmenttothegenericinfrastructuralfacilitieswhichwillattheveryleast
beneededtorealizethee-medicationrecord.Itiswithinthiscontextthatthebasic
infrastructurespecificationshavebeendrawnup.Thesewillthenbeextendedand
optimized.
1� ICTinDutchHealthcare:AnInternationalPerspective 1� ICTinDutchHealthcare:AnInternationalPerspective
Choices in the Netherlands:
• Allmedicaldatatoremaininlocalrepositories;exchangevia
aNationalSwitchPoint.
• Nationalregistersforidentificationandauthentication.
• Nopatientsmartcardwithwhichthehealthcareprovidercanaccesspatientdata.
• MessagestandardizationbasedonHL7v3.
• SecurityviaNENnorm7510(ISO799).
3.3 EMD/WDH implementation programme
IntheEMD/WDHimplementationprogrammethecomponentsofthebasicinfrastructure
andthefirsttwoapplicationscometogether.Thedifferentcomponentswillhaveto
operateinconcertinatestenvironment.FiveEMDandsixWDHpilotregionshavebeen
selectedforthistrialandwillreceiveactiveassistancewiththeintroductionofoneor
bothapplications.Together,thesepilotregionscover1,000healthcareprovidersand
some2millionfiles.Formoreinformationsendane-mailtoinfo@invoering-epd.nl
Care provider Number
GPs 724
Publicpharmacies 286
Hospitals 7
Locumposts 34
Total 1051
Besidesthepilottrial,thereareotherwaysinwhichhealthcareprovidersareclosely
involvedintheintroductionoftheEMDandtheWDH.Fourworkgroupshavebeen
formedtodefinethefunctionalneedsandwishesofthehealthcareprovidersinthe
programme.TheseworkgroupsarefocusingoneverydayaspectsoftheEMDandthe
WDH,suchasthetechnicalrequirementsofthehealthcareandadministrativeprocesses
atpharmacies,GPpracticesandhospitals,andonmeetingtheGBZstandards.
Toensureoptimalcareandattentiontheimplementationprocesshasbeensplitinto
threephases:
1 Proof of Concept (PoC)
TheimplementationoftheElectronicMedicationRecordandtheElectronicGeneral
Practitioner’sRecordbeginswitha‘ProofofConcept’(PoC)phase.InthePoCallthe
constituentsofthechain(LSP,(LSP,SBV-z(sectoralmessageservicesincare),theCitizen
ServiceNumber,theUZIregister,theUZIpassandtheICTsystemsofthehealthcare
providers)aretestedinconcertunderlaboratoryconditions.Thiswillshowwhetherthe
nationalfacilitiesareworkingeffectivelyandwhetherthetestedhealthcaresystemsare
operatingcorrectlyandsafelyintandemwiththenationalfacilities.Oncethisphasehas
beensuccessfullycompletedthesystemsofthesupplierscanbeimplementedinthe
environmentsofthehealthcareproviders.
2 Pilot in pilot reference environment
InthesecondphasetheresultsfromtheProofofConceptareintroducedinthe
healthcaresectoroftwoofthepilotregions(thereferenceenvironments):oneEMD
andoneWDHregion.ThispilotcanonlyproceediftheProofofConceptphasehasbeen
completedandapprovedandtheGBZcriteriahavebeenmet.
Previousexperienceofthistesthasshownthatthesystemsmayneedmodification.
Thesystemsthendefinitivelybecomeoperationalintherespectiveregion.
3 Pilot in other pilot regions
Afterthepilotshavebeensuccessfullycompletedinthereferenceenvironmentsand
anyflawsinthesystemhavebeenredressed,theimplementationintheotherpilot
regionscanstart.
Iftheseprovesuccessfulthenationalroll-outbeginsearlyin2007.
3.4 Other aspects
NowthatthebasicinfrastructureandtheapplicationsforEPDarebeingimplemented,
themanyhealthcareandbusinessapplicationsviaInternetwhicharedevelopedinthe
Netherlandswillgetasafeandreliablebasisfordataexchange.
Healthcareapplicationswillespeciallybenefitfromthenewbasicinfrastructure.Take,
forexample,e-mailconsultations,Internetapplicationsinthementalhealthsector,
Noord-Holland Noord
Rijnland & Midden-Holland
Rijnmond
AmsterdamHarderwijk
UtrechtNijmegen
Twente
Drenthe
Friesland
WDH
EMD
1� ICTinDutchHealthcare:AnInternationalPerspective 1� ICTinDutchHealthcare:AnInternationalPerspective
tele-dermatologicalconsultationsand‘screen-to-screencare’innursing.In2004the
DutchgovernmentlaunchedtheDeclaratiecasusprogramme,aprojecttoimprove
billinginthecaresector(everyyeartheinsurersreceivemillionsofmedicalbillsfrom
thousandsofcareproviders).
ThoughtheneedtodeployICTtohelpsafeguardaffordableandaccessiblehealthcareis
beyonddispute,manyofthetele-medicineapplicationsarehavingdifficultybecoming
apart(bothorganizationalandfinancial)ofthemainstreamhealthcareprocess.Their
effectivenesswillhavetobeprovenbeforetheycanbeintegratedinthecurrentfunding
systemand–ifnecessary–connectedtothenationalinfrastructure.Anadditional
obstacleisthatthecostsandbenefitsofinvestmentandoperationareusuallyspread
acrossdifferentplayers.However,thepotentialprofitsfromtele-medicineandthe
potentialforbroadapplicationarebecomingmorediscernibleallthetime.
TheDutchgovernmenthaslaunchedvariousprogrammestoupsizespecificICT
projectsorprojectsinwhichICTplaysarole,suchasSnellerBeter(FasterBetter),Zorg
voorBeter(GettingBetter)andtheNationwideActionPlanforSocialSectors
andICT(2005-2009).
3.5 Conditions
PrimaryresponsibilityforthequalityofhealthcareandtheuseofICTsystemsrests
withthehealthcareproviders.Itisthegovernment’stasktopavethewayandfacilitate
andstimulatetheuseofICTinhealthcarebypassinglegislation,creatingaconducive
financialclimateandcoordinatingtheprocess,allwithaviewtoimprovingaccessibility,
affordabilityandquality.
3.5.1 Legislative framework
Theprovisionofresponsiblecareandtheuseofmoderntoolsinpresent-dayhealthcare
fallsundertheQualityofHealthcareInstitutionsAct(KwaliteitswetZorginstellingen).The
MedicalTreatmentAct(WetGeneeskundigeBehandelovereenkomst)requireshealthcare
providerstokeeprecordsandthePersonalDataProtectionAct(WetBescherming
Persoonsgegevens)setsprivacycriteriafortheprocessingofpersonaldata.Thecurrent
legislation,whichappliesto‘paper’records,offersanadequatelegislativeframework
foranEPD.Thelegislativeframeworkwill,however,havetobeamendedtocover
informationsearcheswiththeCitizenServiceNumber(BSN)andtoencourageall
healthcareproviderstomakeuseofElectronicHealthRecords:
A. Legislation on the use of the Citizen Service Number (BSN) in healthcare
Thislegislationregulatestheuseofanationalidentificationnumberinthehealthcare
sectorinawaythatenablesmedicaldatatobeuniquelylinkedtoonepatientacross
multipleinformationsystems.TheBillisawaitingdebatebytheDutchParliament.
HealthcareworkersandorganizationswillbeobligedtoentertheBSNintheirrecords,
confirmthatitbelongstothepersoninquestion,andtouseitintheelectronicexchange
ofdata.
B. Legislation on the Electronic Health Record (EPD)
Theaimofthislegislationistoaddressissues,suchassecurity,dataquality,
authorizationandaccess(bythepatientamongstothers),standardizationandtheactual
useoftheEPD.
LegislationforthenationwideElectronicHealthRecordshouldregulateattheveryleast:
• (mandatory)connectionofhealthcareproviderswiththeNationalSwitchPoint;
• electronicavailabilityofpatientdataviatheNationalSwitchPoint;
• secureandreliableinformationexchangeviatheNationalSwitchPoint.
Initially,thelegalobligationwillapplyonlytohealthcareproviderswhoarerequiredto
testtheoperationoftheEMDandtheWDH.Ifnecessary,thelegislationcanbeextended
tootherprovidersandotherpartsoftheElectronicHealthRecord.
3.5.2 Funding
Thenationalfacilitiesfortheinfrastructurewillbefundedbythestate–atleastinthe
earlyyears.ThisconsistsofthedevelopmentandmanagementoftheNationalSwitch
Pointandtheregistersofcareprovidersandhealthinsurers.Thegovernmentwillalso
fundthefirstissueoftheUZIpassandthecard-reader.
Further,thegovernmentwillcontributefinanciallytotheimplementationoftheEMD/
WDHinthepilotregions,wherebytheICTsupplierswhowishtoparticipateinthe
frontrunnerprojectwillgetthechancetoadapttheirsystems.Thelocaluserswillpay
forimplementationatlocallevel–connectingthesystemwiththeNationalSwitchPoint
–andthedataexchange.
TheannualbudgetforICT–currentlyintendedforallcomponentsofthebasic
infrastructureandtheEMD/WDHimplementationprogramme–amountstoover
€ 35million.
3.5.3 Coordination
Mostofthecentralfacilitiesfortheprogrammeareready,sotheemphasishasshifted
fromdesignandconstructiontoactualimplementationofthefirsttwoapplicationsin
concertwiththecentralfacilities.Asthisrequiresacentralpointofcontact,theMinistry
ofHealth,Welfare&Sportisresponsibleforcoordinatingtheprocessfrom1January
2006.Hence,aseparateimplementationorganizationhasbeensetupwithintheministry
forthispurpose.Itstaskistwofold:firsttosupportandfacilitatetheintroductionofthe
ElectronicMedicationRecordandtheElectronicGeneralPractitioner’sRecordinthepilot
region;andsecond,tocoordinatetheentireoperation.
1� ICTinDutchHealthcare:AnInternationalPerspective 1� ICTinDutchHealthcare:AnInternationalPerspective
4 EU eHealth Action Plan
4.1 Introduction
TheeHealthActionPlanispartoftheEuropeanUnion’se-Europestrategy,whichaimsto
bringthebenefitsoftheinformationsocietywithinreachofallEuropeancitizens.
TheprimaryobjectiveoftheeHealthActionPlanistoenabletheEUtoutilizethefull
potentialofon-linehealthcaresystemsandserviceswithinaEuropeanspacefor
eHealth.
Threespearheadshavebeendefined:
• Developastrategyforcommonchallengesandcreateaframeworkconduciveto
eHealth;
• Organizepilotprojectstokick-starteHealth;
• Disseminatebestpracticesandevaluatetheprogress.
TheeHealthworkgrouphasprioritizedthefollowingelementsintheActionPlan:
• Patientsummary
• Identityofcitizens/patientsandhealthcareprofessionals
• Emergencydataset
OntheadviceoftheworkgroupaStakeholdersGrouphasbeenformedtofleshout
theseissues.
4.2 A strategy for common challenges
A Healthcare institutions have an important job to do
TheActionPlanproposesthateachmemberstatedevelopsanationalorregional
roadmapbymid-2006atthelatest.Thisroadmapmustcontainacontinuousagendaand
befinalizedintheautumnof2006.
Situation in the Netherlands:
• TheDutchgovernmentwillpresentitseHealthroadmapatthe‘HighLevel
eHealthconference’inMalagaatthestartofMay2006.
B Interoperability of the healthcare information systems
Interoperablehealthcareinformationsystemsmustensureunambiguousidentification
ofpatientsandtransparentexchangeofhealthcaredatathroughoutEurope.
TheActionPlanthereforeproposesthatthememberstatesformulateacollective
strategyforpatientidentificationbytheendof2006andreachagreementon
interoperabilitystandardsformessagescontainingmedicaldataandelectronicmedical
�0 ICTinDutchHealthcare:AnInternationalPerspective �1 ICTinDutchHealthcare:AnInternationalPerspective
files.Thestrategymustalsotakeaccountofbestpractices,relevantstandardization
activitiesandrecentdevelopmentsin,forexample,theEuropeaninsurancecardand
identitymanagementforEuropeancitizens.
Situation in the Netherlands:
• Identification:inFebruary2006theDutchorganizedaEuropeanExpertMeeting
onHealthIDManagement.TheresultsareduetobeannouncedinMay2006.
Atthesametime,theDutchwillmakethenationalsolutionforpatientsand
healthcareprovidersaccessibleforinternationalharmonization.
• Interoperabilityformessagetraffic:theDutchhaveoptedtostandardize
messagesviaHL7version3,asthisisaninternationalstandardwhichoffers
potentialfordevelopingfurtherwithonestandardfromanationalEMD/WDH
toanationalElectronicHealthRecord.
• Standardization:thisisessentialinordertorealizetheeHealthobjectives
inEurope.TheDutchregardtherecommendationsoftheCEN/ISS‘eHealth
StandardizationFocusGroup’(14March2005)asthebasisforacollective
strategyonstandardization.
• Europeaninsurancecard:theEuropeaninsurancecardwasintroducedinthe
Netherlandson1January2006.Thecardisnotyetconnectedtoanelectronic
functionality.TheDutchgovernmentisnotinfavourofconnectingthiselectronic
cardtopatientidentity,nordoesitseethecardasakeyforaccessingor
supplyingmedicaldata.
C Mobility of patients and healthcare professionals
PatientsandhealthcareworkersarebecomingevermoremobilewithintheEU.
TheEUhasalreadyadoptedastatementonpatientmobilityandstartedprojectsto
improveinformationservicesinthisdomain.Informationonthemobilityofpatients
andhealthcareprofessionalswillbeimprovedbytheactivitiesoftheworkgroupon
healthcaresystems.
Situation in the Netherlands:
• TheDutchgovernmentisworkingonanationwideElectronicHealthRecord
whichwillmakehealthcareinformationavailabletoauthorizedusersregardless
oftimeorplace.
• TheDutchareplayinganactiveroleintheEuropeandebateonthemobilityof
patientsanddoctorswithintheEU.Besidesitsinterestinstandardizationfor
futureideals,theDutchsupportpragmaticsolutionsforbottlenecks.
D Modernization of infrastructure and technology
TheActionPlanrequiresthememberstatestosupporttheconstructionofeHealth
informationnetworksin2004-2008onthebasisoffixedandwirelessmobileand
broadbandinfrastructureandgridtechnology.
Situation in the Netherlands:
• TheNationwideActionPlanforSocialSectorsandICT(2005-2009)isalsogeared
toapplicationswhichneedbroadband(utilizationofbroadband).
• ThereisahighlevelofbroadbandcoverageintheNetherlands.InarecentOESO
studytheNetherlandsscoredhighinbroadbandpenetration,withover
25subscriptionsper100inhabitants.
E Conformity tests and accreditation for an eHealthcare market
NumerousEuropeancountrieshavealreadyembracedtheaccreditationofelectronic
healthcaresystems,whicharenowservingasmodelsforotherregions.
Bymid-2006atthelatesttheCommissionmustcompilealistofbestEuropeanpractices
asaguidelineforthememberstates.Bytheendof2007thememberstatesmustthen
organizeconformitytestsandaccreditationonthebasisofsuccessfulbestpractices.
Situation in the Netherlands:
• In2006thebasicinfrastructureisduefortestinginpilotenvironments.
• In2007certificationschemeswillbereadyforthelocalinformationsystems(GBZ/
well-managedhealthcaresystems)forconnectiontotheNationalSwitchPoint.
F Investment incentives
Eachdevelopmentormodernizationofthesystemsrequiresinvestment.Accordingly,
thememberstates–inlinewiththeActionPlan–mustdevelopajointstrategybythe
endof2006tosupportandstimulateinvestmentineHealth.
Situation in the Netherlands:
• Upsizing:TheDutchgovernmentisencouragingtheupsizingofdevelopments
inICTsystemsandservicesviaaNationwideActionPlanfortheSocialSectors
andICT.
• Attheendof2006theDutchwillexchangeinformationwithothercountrieson
defrayingthecostsofeHealth.
G Judicial and regulatory aspects
UndertheActionPlantheEuropeanCommissionmusttakejointactionwiththemember
statesbytheendof2009to:
• establishareferenceforastandardizedEuropeanqualificationforeHealthservicesin
aclinicalandadministrativesetting;
�� ICTinDutchHealthcare:AnInternationalPerspective �� ICTinDutchHealthcare:AnInternationalPerspective
• createaframeworkformorelegalsecurityinrelationtoproductandserviceliability
ineHealthwithinthecontextoftheexistinglegislationonproductliability;
• improvetheinformationforpatients,healthinsurancesystemsandhealthcare
providersonhowtoreclaimthecostsofeHealthservices;
• promoteeHealthtoreduceindustrialaccidentsandoccupationalillnessesandto
findwaysofpreventingnewrisksintheworkplace.
4.3 Pilot projects
ManypilotprojectsoneHealtharealreadyunderwayintheEuropeanUnionorwillstart
verysoon.
H Information for citizens and governments on health education and
prevention of illness
AspartofitspublichealthprogrammetheEuropeanCommissionhasbeenworkingona
publichealthportalsitefortheentireEU,scheduledtobeoperationalattheendof2005.
Thissiteofferscitizensonepointofaccesstoinformationonpublichealthandalsoon
healthandsafetyintheworkplace.
TheECisalsoimprovingtheICTinstrumentssothatearlywarning,detection,and
surveillanceofthreatstopublichealthcanbesteppedup.
Situation in the Netherlands:
• In2005aportalwassetupintheNetherlandsofferingcomparativeandhealth
informationtomembersofthepublic.Thisportalcontainsinformationon
hospitals,healthinsurance,medication,patientinterestandmedicalissues
(www.kiesbeter.nl).In2006and2007theportalistobefurtherextendedwith
informationon,amongstothers,GPs,physiotherapists,residentialcareand
nursinghomes,homecare,mentalhealthcareandcareforthehandicapped.
• ItwillbeharmonizedwiththeEUportalsitein2006.
I The development of integrated healthcare information networks
Atpresent,alotofworkandenergyisbeinginvestedintheinterconnectionofhealthcare
informationnetworks.Bytheendof2008mostEuropeanhealthcareorganizationsand
regions(municipalities,provincesetc.)mustbeabletoofferon-lineservicessuchas
tele-consultations(secondmedicalopinion),electronicprescriptions,electronicreferralto
specializedservices,tele-monitoringandtele-care(monitoringthepatientathome).
Situation in the Netherlands:
• TheNetherlandswillactivelylookintotheinitiativesofothermemberstates
tointegratedomotica,telemedicineandstandardizationconcerningElectronic
HealthRecords.
J Encouraging the use of cards in the healthcare sector
Therearetwotypesofcardthatcanbeusedinthehealthcaresector:thehealthcare
pass,whichcontainsusefulinformationforemergencies,suchasbloodgroup,
medicalconditionsandtreatment;andtheEuropeanhealthinsurancecard,whichwas
launchedon1January2004andreplacesallthepapersthatpeopleusedtoneedto
getemergencymedicalcareduringastayabroad.Thememberstatesareorganizing
campaignstoencouragepeopletousethesecards.Ithasalsobeenagreedthatthe
principleoftheelectronichealthinsurancecardwillbeapprovedby2008.
Situation in the Netherlands:
• OntheissueofpatientaccesstotheirownmedicalrecordstheDutchare
focusingontheelectronicnationalidentitycardwhichwillbeintroducedin2007.
• PatientswillnotbeabletousetheEuropeaninsurancecard,introducedon
1January2006,toaccesstheirownrecords.TheNetherlandsisplayingan
activeroleinthedebateontheelectronicinsurancecardwhichtheEUplans
tointroducein2008.
4.4 Monitoring
K Dissemination of best practices
eHealthcaremustbesupportedbythelarge-scaledisseminationofbestpractices.The
keyissuesaretheeffectsonaccesstohealthcare,thequalityofhealthcare,anevaluation
ofcostsavingsandproductivitygains,andmodelsforastrategytoaddressliabilityfor
tele-medicalservices,reimbursementproceduresandaccreditationofeHealthproducts
andservices.
Thedisseminationofbestpracticesneedstobesafeguardedbyregularhigh-level
conferenceswhichenjoythesupportoftheEuropeanCommission.Meantime,the
Commissionmustintroduceaneffectivesystemfordisseminatingbestpracticesbythe
endof2005.
Situation in the Netherlands:
• TheNetherlandswillactivelyshareitsbestpracticeswithothermemberstates.
AnEnglishoverviewwillbeavailableatthestartof2007.
L Evaluation
TheEuropeanCommissionhasundertakentopublishabiennialevaluationinthecourse
of2004-2010ontheprogressintheintroductionofeHealthcare.
Situation in the Netherlands:
• TheNetherlandswillactivelycontributetobiennialevaluationbytheEC.
�� ICTinDutchHealthcare:AnInternationalPerspective �� ICTinDutchHealthcare:AnInternationalPerspective
Appendix 1
Health indicators - The NetherlandsSource:www.who.org
Population EstimatesIndicator Value
Totalpopulation(000),2003 16,149.0
Annualpopulationgrowthrate(%),1993to2003 0.6
Annualpopulationgrowthrate(%),1993to2003 48.0
Annualpopulationgrowthrate(%),1993to2003 18.7
Totalfertilityrate,2003 1.7
Health IndicatorsIndicator Value
Life expectancy at birth (years) 2003
Totalpopulation 79
Males 76
Females 81
Child mortality (probability of dying under age 5 years) (per 1000) 2003
Males 6
Females 5
Adult mortality (probability of dying between 15 and 59) (per 1000) 2003
Males 93
Females 66
Healthy life expectancy at birth (years) 2002
Totalpopulation 71.2
Males 69.7
Females 72.6
Healthy life expectancy at age 60 (years) 2002
Malesatage60 15.5
Femalesatage60 18.4
Expectation of lost healthy years at birth due to poor health (years) 2002
Males 6.3
Females 8.5
Percentage of total life expectancy lost due to poor health (%) 2002
Males 8.3
Females 10.4
�� ICTinDutchHealthcare:AnInternationalPerspective �� ICTinDutchHealthcare:AnInternationalPerspective
Appendix 2
National expenditure on health - The NetherlandsSource:www.who.org
A Proposed ratios and levels 1998 1999 2000 2001 2002 2003 2004
I. Expenditure ratios
Totalexpenditureonhealth(THE)%GDP 8.2 8.4 8.3 8.7 9.3 9.8 9.8
Generalgovernmentexpenditureonhealth(GGHE)%THE 64.1 62.7 63.1 62.8 62.5 62.4 61.2
Privateexpenditureonhealth(PvtHE)%THE 35.9 37.3 36.9 37.2 37.5 37.6 38.8
GGHE%Generalgovernmentexpenditure 11.2 11.2 11.5 11.5 12 12.4 12.3
Socialsecurityexpenditureonhealth%GGHE 93.9 93.8 93.9 93.8 93.8 93 93.3
Netout-of-pocketspendingonhealth(OOPs)%PvtHE 23.6 24.1 24.3 23.4 21.4 20.8 20
Privateprepaidplansexpenditureonhealth%PvtHE 45.6 44.5 43 43.6 45.6 45.7 46.4
Externallyfundedexpenditureonhealth%THE 0 0 0 0 0 0 0
II. Per capita levels
THEpercapitaatexchangerate(US$) 2067 2102 1916 2067 2411 3088 3471
GGHEpercapitaatexchangerate(US$) 1326 1318 1209 1298 1506 1926 2123
THEpercapitaatinternationaldollarrate 2044 2124 2270 2517 2777 2987 3056
GGHEpercapitaatinternationaldollarrate 1311 1332 1432 1581 1735 1863 1869
B Values underlying ratios and levels
Health System Expenditure & Financing (million NCU)
I.MeasuredFinancingAgents
Totalexpenditureonhealth(THE) 29221 31236 33261 37150 41264 44589 45754
Generalgovernmentexpenditureonhealth(GGHE) 18744 19589 20981 23333 25773 27815 27981
…ofwhichSocialsecurityexpenditureonhealth 17604 18367 19696 21881 24165 25856 26095
Privateexpenditureonhealth(PvtHE) 10477 11649 12280 13817 15491 16774 17773
…ofwhichNetout-of-pocketspendingonhealth 2469 2807 2987 3232 3310 3496 3548
...ofwhichPrivateprepaidplansexpenditureonhealth 4778 5186 5280 6029 7070 7673 8255
II.MeasuredFinancingSources
Externallyfundedexpenditureonhealth 0 0 0 0 0 0 0
III.MacroVariables
Grossdomesticproduct(GDP)(millionNCU) 354194 374070 402291 429345 445160 454276 466310
Generalgovernmentexpenditure(millionNCU) 167216 175554 182228 203063 214960 224231 227535
Exchangerate(NCUperUS$) 0.9 0.94 1.09 1.12 1.06 0.89 0.81
Internationaldollarrate(NCUperinternationaldollar) 0.91 0.93 0.92 0.92 0.92 0.92 0.92
Totalpopulation(inthousands) 15707 15812 15926 16046 16149 16225 16275
�� ICTinDutchHealthcare:AnInternationalPerspective
Appendix 3
Healthcare professionals - The Netherlands
Health care professionals Number in 2003 Density per year
Physicians 50854 3.15
Nurses 221783 13.73
Midwives 1940 0.12
Dentists 7759 0.48
Pharmacists 3134 0.19
Publishedby:
MinistryofHealth,WelfareandSport
Addressforvisitors:
Parnassusplein5
2511VXTheHague
TheNetherlands
Correspondenceaddress:
PObox20350
2500EJTheHague
TheNetherlands
Telephone+31(0)703407911
Telefax+31(0)703407834
Internet:
www.minvws.nl
May2006
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